Provider Demographics
NPI:1285979377
Name:DALE, JENNA MARIE (OD)
Entity type:Individual
Prefix:DR
First Name:JENNA
Middle Name:MARIE
Last Name:DALE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:MARIE
Other - Last Name:LIECHTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:322 S. WOODCREST DRIVE PRECISION EYE GROUP
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401
Mailing Address - Country:US
Mailing Address - Phone:812-332-2020
Mailing Address - Fax:
Practice Address - Street 1:322 S. WOODCREST DRIVE PRECISION EYE GROUP
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401
Practice Address - Country:US
Practice Address - Phone:812-332-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-30
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003771A152WP0200X, 152WV0400X, 152W00000X
TN3035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy